SESSION TYPE: Infectious Disease Student/Resident Case Report Posters III
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: Mycobacterium tuberculosis (MTB) infection with miliary spread, MTB otitis media and otomastoiditis are rarely reported together. This case’s rapid progression from seemingly indolent ear infection to overwhelming sepsis in an immunocompetent patient highlights the invasive nature of this well-known infectious agent.
CASE PRESENTATION: A previously healthy 19-year-old man presented to our hospital with two weeks of left ear discharge and pain, and three days of progressive shortness of breath and dry cough. Initial vital signs and laboratory work-up suggested severe sepsis. His physical examination revealed a calm affect contrasting with the degree of tachycardia and tachypnea. He had an inflamed tympanic membrane, mild mastoid tenderness and purulent discharge emanating from the left external auditory canal. Chest imaging, including CT, showed enumerable 2-3 mm random miliary nodules with focal coalescence forming patchy areas of consolidation. His condition rapidly deteriorated to hypoxemic respiratory failure and shock, requiring intubation and vasopressor support. Acid-fast stains of the sputum and left ear discharge returned strongly positive and were confirmed as MTB by nucleic acid amplification. CT brain with temporal bone sequences demonstrated left-sided otitis externa and complete opacification of the left mastoid air cells and middle ear cavity with dehiscence of the inner mastoid cortex (image 1). Brain MRI was notable for numerous ring-enhancing lesions scattered throughout both cerebral and cerebellar hemispheres, and medulla, with surrounding vasogenic edema—consistent with tuberculomas (image 2). The patient responded well to treatment with anti-MTB chemotherapy and systemic corticosteroids. Within a week of admission he was liberated from ventilatory and vasopressor support and was subsequently transferred to our TB unit.
DISCUSSION: MTB otitis media and otomastoiditis are seldom reported in adults, even less when associated with miliary spread. Their presentation is often indolent and their treatment benefits from early diagnosis because of the high degree of local invasive damage they can produce. This case is unique in that it represents MTB otitis media likely leading to otomastoiditis and subsequent severe disseminated pulmonary and central nervous system (CNS) disease.
CONCLUSIONS: The rapid evolution in an immunocompetent patient over a period of weeks, from middle ear infection to pulmonary and CNS disease resulting in septic shock and respiratory failure, demonstrates the potential for aggressive dissemination of MTB.
1) Dale, OT et al. “ Challenges encountered in the diagnosis of tuberculous otitis media: case report and literature review.” Journal of Laryngology and Otology. 125.07 (2011): 738-740. Web. 9 Apr. 2012. DOI: <10.1017/S0022215111000971>.
DISCLOSURE: The following authors have nothing to disclose: Richard Tennant, Nader Kamangar
No Product/Research Disclosure InformationOlive View - UCLA Medical Center, Sylmar, CA